General Requirements for the Electronic Claims Submission Process (837 Institutional Claims)
EDI Claims guidelines facilitate the Institutional Claims Submission Process. Only loops, segments, and data elements valid for the HIPAA 837 Institutional (005010X223A2) Technical Report Type 3 will be translated. Deviating from the Technical Report Type 3 Guidelines and submitting invalid data will cause files to be rejected. Only one transaction type per transmission.
The delimiters which Health Partners Plans will accept are listed below. The following characters must not be used within the data content of the 837I:
- Data Element = * (Asterisk)
- Segment = ~ (Tilde)
- Component/Element = < (Less than sign)
No more than 5,000 claims should be submitted by any provider at one time. WebMD/Emdeon Business Services will perform HIPAA compliance checking for all transactions received. If the transaction fails compliance checking, a “997 Functional Acknowledgement – Reject” will be generated and transmitted to the provider. The provider will be expected to correct the data and immediately retransmit the transaction.
Rejected claims must be resubmitted within 180 days of the original date of service.
Negative values submitted in the following fields will not be processed and will result in claim rejections: Total Claim Charge Amount (2300 Loop, CLM02), Patient Amount Paid (2300 Loop, AMT02), Other Payer Patient Paid Amount (2320 Loop, AMT02), COB Total Allowed Amount (2320 Loop, AMT02).
Health Partners suggests retrieval of the ANSI 997 Functional Acknowledgment files on the first business day after the claim file is submitted, but no later than five days after the file submission.
Providers submitting claims for Institutional Services should enter their five (5) digit Health Partners Provider Identification Number in the 2310A REF01 ‘G2’ qualifier, as shown in the table “837 Institutional” on page 6 of this companion guide. Health Partners Plans Claims Technical Support is available Monday through Friday, 9:00 a.m. to 5:00 p.m. (EST).
To learn more about HIPAA EDI and become a certified EDI Professional please visit our course schedule page.